Prohibiting smoking outside hospital buildings: consultation analysis

Executive Summary

The Scottish Government is committed to raising a tobacco-free generation by 2034 and to reduce the prevalence of smoking to 5% or less by that same year.^[1] Indeed, "a Scotland where we reduce the use of and harm from alcohol, tobacco and other drugs" is identified as one of six Public Health Priorities for Scotland.^[2]

The NHS should be an exemplar of health promotion and support people in their efforts to stop smoking - accessible and open places which promote good health and lifestyle choices. Despite NHS Scotland adopting a smoke-free hospital grounds policy across all of its hospital sites in 2015, people smoking on hospital grounds continues to be a nuisance and poses a potential health risk to patients, visitors and staff. While the smoke-free grounds policy has had some impact, smoking on hospital grounds continues to be the subject of many complaints to health boards and to government.

The Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 amended sections of the Smoking, Health and Social Care (Scotland) Act 2005 to allow offences to be introduced in respect of smoking around hospital buildings. The 2005 Act now provides for the introduction of formal no-smoking areas outside hospital buildings and for offences of allowing smoking in these areas and of smoking in these areas. The main aims of introducing a formal no-smoking area around hospital buildings are to: support the de-normalisation of smoking; help reduce the use of tobacco across the population; and prevent or reduce exposure to second-hand smoke.

The Act gives Ministers the powers to make secondary legislation ("Regulations") to finalise the details before these provisions can be brought into force. The Scottish Government has worked with health boards and other stakeholders to develop practical proposals for an effective set of regulations that will persuade people to respect others and not smoke around hospital buildings.

This document presents the main findings from an analysis of responses to the Scottish Government consultation on Prohibiting Smoking Outside Hospital Buildings. The purpose of this consultation was to seek views on the three matters which remain to be determined:

1. The distance from hospital buildings which will form the perimeter of the no-smoking areas outside a hospital building, and how the perimeter around the building is determined in so far as whether the perimeter ends the specified distance from a wall or from any part of the building structure or otherwise.

2. The manner of display, form and content of no-smoking notices.

3. Whether there are any exceptions required for specific hospitals or specific buildings, or specific areas of land which should not be considered hospital grounds or part of the no-smoking areas respectively under the definitions in the Act.

The consultation also sought views on the use of Nicotine Vapour Products (NVPs) - including electronic cigarettes - around hospital buildings, a question not raised at the time of the 2005 Act.^[3] Many NHS Boards allow vaping but some do not. There is a need for consistency, a Scotland-wide approach, and clear guidance to health boards on whether the use of NVPs on hospital grounds should be allowed as an alternative for smokers visiting or working in hospitals.

The findings from this consultation will be used by Ministers to finalise the detail of the Regulations, and for these provisions to be laid in the Scottish Parliament.

The consultation received a total of 559 responses. The vast majority of submissions were from individuals (92%), many of whom worked in the health sector in Scotland.^[4] The consultation attracted responses from a diverse range of organisations, including NHS bodies, third sector organisations (e.g. health improvement organisations and charities, smokers' rights bodies), medical professional bodies, and other public sector bodies.

Table 1: Summary Analysis Table

Q1 - Do you support the proposal that the distance from hospital buildings which will form the perimeter of the no-smoking areas outside a hospital building should be 15 metres?

Main Feedback: The majority supported the proposal

• The proposed distance was considered justified by a majority to significantly reduce health risks for patients, visitors and staff. The areas around hospital buildings where smoking is most prevalent was considered harmful and presented a public health risk to anyone entering or leaving hospital buildings.
• Concerns were raised about the practicalities of effective enforcement, and that it might be complicated to explain and for the public to understand (and gauge what 15 metres looks like). Many noted that the perimeter should extend beyond this distance (ranged from 20 to 50+ metres) or that there should be a statutory ban on all hospital grounds.
• There was some feedback that the proposal was restrictive, and lacked compassion for those who want to smoke/who are addicted to nicotine/who smoke as a coping mechanism.
• There was support for designated smoking areas, although there were concerns raised about how disabled people, those with mobility issues, older people and the infirm could easily access these areas.

Q2 - Do you support the proposal that the perimeter should be measured from the outside wall of a building and include all land or area under any canopy or overhang even where those extend beyond 15 metres?

Main Feedback: The majority supported the proposal

• The main feedback was that the perimeter should be greater than 15 metres and/or that the ban should cover all hospital grounds.
• These points aside, the proposal was considered vital to ensure that smoking on hospital grounds was undertaken at a safe distance from others entering, leaving or moving between hospital buildings.
• It was reported that people tend to congregate under canopies and overhangs to smoke, and that semi-enclosed areas are used as impromptu smoking shelters. A common view was that the proposal could help reduce exposure to second-hand smoke.
• However, some respondents suggested that the perimeter distance should be measured from the point where any canopies/overhangs end.
• Some felt that managing the implementation of this perimeter could be more challenging than if the ban covered all hospital grounds.
• Some respondents felt that the proposal was too "punitive" against smokers.

Q3 - Do you support the proposal to set the wording and dimensions of no smoking notices as described above?

Main Feedback: The majority supported the proposal

• Most of those that agreed with the proposal did not provide any wider comment on proposed wording or dimensions of notices.
• General feedback: all notices must be clear and prominent; standardised wording across NHS hospital sites to ensure consistency of key messages; current no-smoking signage is perceived to be largely ignored and the smoke-free hospital grounds policy is not effectively enforced; signage on its own might not be sufficient to encourage people to respect smoke-free areas, or to achieve the Scottish Government's stated goal of reducing the use of tobacco; comprehensive guidance to be provided to health boards/hospitals on roles and responsibilities and on enforcement; and concerns about the potential verbal abuse, confrontation, and/or aggressive behaviour staff might receive should they challenge someone smoking in a no-smoking area.
• More specific feedback included: some support for "stronger" wording to be used on notices; that signs should include details of the fines that would be imposed; the importance of sign-posting to smoking cessation support services; sign-posting to designated smoking areas.
• Some felt it was unfair that the onus was being placed on all hospital staff to enforce the new Regulations, and that there should be a designated person/office (with contact details).

Q4 - Do you support the proposal that no specific hospital or type of hospital should be exempted under the definition of "hospital" in the Act?

Main Feedback: The majority supported the proposal

• It was considered essential that the new Regulations were applied across all "hospitals" as part of a key national health intervention, and for the NHS to be viewed as an exemplar of health promotion and in supporting people to stop smoking.
• While there was broad recognition that some "hospitals" might want an exemption (e.g. psychiatric hospitals), respondents that supported the proposal pointed to a range of wider considerations including the strong correlation between poor mental health and smoking behaviour.
• Both supporters and non-supporters of the proposal did raise some points of concern, namely: how the Regulations would be managed in psychiatric hospitals where patients, for example, can currently smoke in secure courtyard areas and patients who lack capacity to understand the legislation and its implications, and who might not be able to make an informed choice regarding smoking cessation; issues around risk and security for patients and staff; and support for designated smoking areas for those who are in hospital on a long term basis (e.g. hospices), and those in mental health facilities.
• Some felt that there might be extenuating circumstances for certain "hospitals", and certain categories of patients, and/or that reasonable adjustments could be considered. For example, some felt that it would be discriminatory or inhumane to remove access to nicotine products from people who are detained under Mental Health (Care & Treatment) (Scotland) Act.

Q5 - Do you support the proposal that no-smoking areas will only apply to buildings used wholly or partly as a hospital?

Main Feedback: Around half supported the proposal

• The vast majority of respondents that supported the proposal did not provide any wider commentary. Where comments were made this included: a preference for the Regulations to apply to all NHS buildings to avoid any confusion, or that there should be no smoking allowed on the entire extent of hospital grounds; and that further detail would be important to support implementation.
• The main feedback from the cohort of respondents who did not support the proposal was that no-smoking areas and perimeters should apply to all NHS buildings situated on hospital grounds, including any heath care, service and administrative buildings (i.e. all NHS buildings regardless of their use). These respondents also noted the potential for confusion and challenges around enforcement. Wider feedback was that those visiting and/or working in the buildings who are proposed to be excluded from the definition deserve the same level of protection from exposure to second-hand smoke as patients, visitors and staff entering, leaving or walking past buildings used wholly or partly as a hospital.

Q6 - Do you support the proposal that public footpaths, cycle paths and footways should be considered hospital grounds for the purposes of establishing no-smoking areas outside the doorways of hospital buildings, and that the size of the grounds would extend up to 15 metres from the centre of doorways?

Main Feedback: The majority supported the proposal

• The vast majority of respondents that agreed with the proposals outlined above did not provide any wider commentary.
• Where comments were made, the main point raised was that smoking should be prohibited in areas classed as hospital grounds to limit exposure to second-hand smoke and the harm caused by passive smoking.
• A number of respondents also commented on the proposal that the size of the grounds would extend up to 15 metres from the centre of doorways. The main feedback was that it should either extend beyond 15 metres or apply to all hospital grounds.
• The main feedback from respondents who did not support the proposal was that no-smoking areas should relate to the entire extent of grounds associated with NHS hospitals. Points raised throughout the consultation were also mentioned (e.g. NHS should be exemplar of health promotion, reduce exposure to second-hand smoke, could be easier to enforce). Linked to these points was that consideration could also be given to sign-posting people to smoking shelters away from hospital building entrances.

Q7 - Do you support the proposal that the use of NVPs should be allowed as an alternative to smoking on hospital grounds but not within the no-smoking area outside hospital buildings?

Main Feedback: Around half supported the proposal

• The vast majority of respondents who supported the proposal did not provide any wider feedback or comment. Where feedback was provided, the main theme was that vaping e-cigarettes should be treated in the same way as tobacco throughout hospital sites in Scotland - for consistency in messaging and communications about the no-smoking perimeter, and for ease of enforcement. Others mentioned that NVPs can be a good smoking cessation tool.
• Many of those who supported the proposal caveated their response by noting a number of points: that the long-term effects of vaping e-cigarettes (to the person using the device and to those exposed to the vapour) were not yet known, and that the evidence base would need to be regularly reviewed; that some people exposed to the flavoured vapour from NVPs can experience breathing irritations (e.g. asthmatics); and that using NVPs emulates the actions of smoking, and could normalise the behaviour among children and young people.
• Some 45% of respondents did not support the proposal. The main points raised centred on: insufficient research into the impact on health and longitudinal data that vaping is less harmful than tobacco products; that exposure to the flavoured vapour is unpleasant and can be harmful to health (e.g. people with respiratory problems); that NVPs should be included in the existing smoke-free hospital grounds policy; that e-cigarettes are not currently regulated as a tobacco product or a medicine in the UK; they can mimic the look of smoking, which may make it harder for others not to smoke; and that there could be some flexibility applied and reasonable adjustments made in implementing the proposal for certain groups.

Q8 - Do you consider there to be any positive or negative impacts on equality as a result of the proposals in this consultation?

Main Feedback: Over one-third agreed that there were positive and/or negative impacts

• The main groups identified by respondents that noted a negative impact(s) on equality as a result of the proposals were disabled people and older people (e.g. inform, mobility issues) - they might experience difficulties walking (safely) from the exterior of a hospital building to smoke.
• People with mental health issues were frequently viewed as a group who could be negatively affected, and in particular those patients detained under the Mental Health (Care & Treatment) (Scotland) Act 2003. Other groups identified who could be negatively affected were people with long-term limiting illnesses, and those from disadvantaged socioeconomic backgrounds. Some respondents noted the negative impact that the proposals could have on smokers (i.e. addictive nature of smoking), while others noted that smokers would be unfairly discriminated against (i.e. legal product/freedom of choice arguments).
• The main mitigation actions identified were accessible smoking shelters and access to smoking cessation support services. There were also some references to nicotine patches and NVPs.
• Where positive impacts were noted, these typically centred on the following: reducing health inequalities; equal protection of patients, staff and visitors to the health harms of Environmental Tobacco Smoke (ETS); encouraging positive change to harmful behaviour; reducing the visibility of smoking for children and young people; reducing adult smoking rates across all demographics and income groups (although to various degrees); supporting people to stop smoking by increased promotion of, and access to, smoking cessation services.